ICHTHYOL IN GYNECOLOGY. 
MALCOLM STOKER, M.D. 
OF BOSTON. 
Read at the Annual Meeting of the Massachusetts Medical Society, 
June 13, 1894. ICHTHYOL IN GYNECOLOGY. 
Sufficient time has now elapsed since the introduction 
of this drug to form some judgment as to its value in the 
treatment of diseases of women. A\ liile many foreign 
writers have given us the results of their experience, so 
little has appeared in this country on the subject that I 
feel justified in laying it before you. 
Much, apparently with justice, has been claimed for 
ichthyol in other departments of medicine; the question of 
its value in gynecology has been somewhat vexed, and it 
may be of interest to give a brief resume of the results of 
some other observers, and see how closely they are borne 
out by personal experience. 
The characteristics of the drug generally employed— 
the sulpho-ichthyolate of ammonium—probably are well 
known to you. Suffice it to say that it is obtained from a 
fossil fish deposit, and is a thick brown liquid, with a 
smoky and to some a highly offensive odor. It is soluble 
in water, in a mixture of alcohol and ether, in oils, glycer- 
ine and tats, and contains about 15 per cent, of sulphur, 
very intimately combined.1 Discovered by Schrotter,2 it 
was introduced to the profession by Unna in 1883, and its 
success in certain inflammatory dermatological conditions 
soon brought it into great vogue. Unna’s theory of its 
action was that by its reducing power it deprives the endo- 
thelium of the bloodvessels of oxygen, and so causes them 
1 Lurtigeau, Gaz. des Hop., 1837. p. 165. 
2 Schrotter, Monatschrift f. Prakt. Dermat., 1882. 4 
ICHTHYOL IN GYNECOLOGY. 
to contract. While this view is vigorously combated, no 
better one has been proposed. (See Elliott.)1 
Its use in Gynecology was first suggested by Freund in 
1890.2 He claimed surprisingly quick and complete cures 
in many cases of chronic parametritis, chronic and subacute 
perimetritis, with exudation and adhesions, cicatricial atro- 
phy of the vagina and cervix, chronic metritis and tubo- 
ovaritis. He also found it valuable for pruritus and cracked 
nipples, and relieved a case of catarrh of the large intestine 
with suppositories. His method in severe cases was to in- 
troduce the drug into the system in a variety of ways, using 
all of the following:—sugar-coated pills containing 1£ 
minim, two to eight daily ; salve, 10 per cent., for inunction 
on abdomen ; rectal suppositories, containing three minims ; 
ichthyol-glycerine tampons, five per cent. 
He claimed, first, an extraordinary resorbent action, and 
secondly, great analgesic power. Subsequent investiga- 
tors all admit its analgesic qualities, but that it also pro- 
motes absorption is as stoutly denied by some as it is main- 
tained by others. 
Following these lines, Reitmann and Schonauer3 reported 
on its use in one hundred inflammatory cases, with most 
gratifying results as regards pain, remarking that the pro- 
perty of promoting absorption also deserves particular men- 
tion. Shortly afterwards Block4 gave his results. He 
too was an enthusiast, and was the first to apply pure 
ichthyol to the endometrium. He was convinced of its 
resorbent as well as anodyne action. Great improvement 
was noticed in cases of acute vaginitis and chronic metritis 
with venous engorgement. That its effects were not due to 
the use of a glycerine solution he proved by a series of 
1 New York Med. Rec. 1887. 
2 Freund, Berl. klin. Wochenschrift, 1890, No. 11 and No. 49. 
3 Reitmann and Schonauer, Wien. klin. Wochenschrift, 1890, No. 23. 
4 Block, Wien. med. Wochenschrift, 1890, No. 50. ICIITIIYOL IN GYNECOLOGY 
5 
control experiments with pure ichthyol, and stated his belief 
that the pure drug was more efficient than the glycerine 
solution. 
Kotschau,1 in fifty-six cases of endocervicitis and endo- 
metritis, of one hundred and twenty-seven in which lie used 
ichthyol, in the severer cases combined a preliminary curet- 
ting with the iron, massage and douches which he employed 
in addition to local treatment, and while treatment with 
other means gives about the same proportion of cures, he 
regards ichthyol as much safer. But when he speaks of it 
as a " sovereign remedy for endometritis,” one must not be 
blind to the fact that many of the cases were previously 
curetted. In fifty-two cases of afebrile perimetritis he was 
satisfied that tampons of ichthyol-glycerine with ichthyol 
pills and hot sitz baths produced a cure more promptly than 
any other treatment, pain being often relieved by the first 
application, and the exudate quickly disappearing. 
Thus far all testimony has been favorable. But in 1891 
Oberth,2 of Chrobak’s clinic, from the study of forty-two 
cases, concluded :— 
1. That the salve had absolutely no power of controlling 
pain. 
2. That while the pills were usually, though not always, 
well borne, no improvement in appetite or general condition 
followed that could be ascribed to them. 
3. That the suppositories had a negative effect as re- 
gards tenesnus, and that they sometimes irritated the rec- 
tum. 
4. That while pure ichthyol applied to the catarrhal 
mucosa or eroded os would often produce a cure, the re- 
sults were by no means as good as those obtained by the 
older astringents. 
The only good of the tampons he believed came from the 
1 Kotschau, Mun. med. Wochenschrift, 1891, No. 1. 
2 Oberth, Wien. klin. Wochenschrift, 1891, No. 16. 6 
ICHTHYOL IN GYNECOLOGY. 
glycerine they contained, and while granting a certain in- 
fluence against pain denies absolutely any action. 
Pee1 arrived at the same conclusions, holding that it 
should be used only symptomatically for pain, and warning 
that its intra-uterine use might be followed by severe hemor- 
rhage. In the discussion that followed his paper, Veit, 
Winter, Schaffer and Bokelmann coincided with the reader. 
Egasse,2 in 1891, remarks that in France the claims of 
Freund have not been substantiated, and that sit Auvard’s 
clinic it has been abandoned. 
Jadassohn3 used it in thirty-seven cases of gonorrhoea, 
using: a one to ten solution, and regards it as more effica- 
cious that even nitrate of silver in the acute stage. Similar 
good effect was observed by Bloch, but denied by Pee. 
Later, Columbini4 and Jullien5 reported its very successful 
use in this disease. 
Ilerff6 7 is a strong opponent of its having other than 
excellent analgesic qualities. He discards its internal use 
as irrelavent, and the salve as merely a form of massage. 
Hermann,8 on the other hand, from one hundred and 
fifty cases in which ichthyol alone was used, either pure or 
in watery solution, finds that it has a distinct resorbent 
action, and even regards it as a sufficient means whereby to 
establish a diagnosis between carcinoma and inflammatory 
induration, as the latter is so quickly controlled by its use. 
Schultz9 thinks it of great value in chronic inflammatory 
conditions. 
1 Pee, Zeitschrift f. Geb. u. Gyn., 1891, No. XX. 
2 Egasse, Bull, de Ther., Paris, 1891, CXXI. 
3 Jadassohn, Deutsche med. Wochenschrift, 1892, 38. 
4 Columbini, Am. J. Obst., Ap., 1894. 
6 Jullien, Med. Week, Ap., 1894. 
6 Ilerff, Mun. med. Wochenschrift, 1891, p. 313. 
7 “ “ “ “ 1892, p. 941. 
8 Hermann, Centralbl. f. Gyn., 1892, 50. 
9 Schultz, “ “ 1893, No. 38. ICHTHYOL IN GYNECOLOGY. 
Polacco,1 from nine hundred and seventy-two cases ob- 
served in Mangiagalli’s clinic, states decidedly that it is 
the most positive local analgesic known in gynecological 
therapeutics, and that furthermore it has an undoubted 
resorbent action in cases of pelvic exudates, and in a sub- 
sequent paper2 he remarks that all authorities admit this. 
I have shown that they do not by any means all do so. 
Albertolelli3 practically had the same experience as the 
last writer. He regarded it as especially well adapted to 
intra-uterine injection, greatly preferring it to tr. iod. 
At the risk of being tedious I have given a hint at most 
that has thus far appeared on the subject, chiefly to show 
that such opposed results could be obtained by observers 
employing much the same methods. Two years ago my 
interest in the subject was awakened, and suspecting that 
some of these results might possibly be biassed, I have tried 
to be entirely fair. While I greatly regret that I have not 
been able to follow all my cases as closely as desirable, 
from what I have seen I feel justified in drawing quite 
definite conclusions. 
While of course occasional applications have been made 
in a much larger number of cases, it was used with more 
or less faithfulness in about one hundred and twenty, but 
as many of these were in the out-patient clinics at the Car- 
ney and St. Elizabeth Hospitals, owing to the exasperating 
irregularity of the attendance of the average out-patient as 
soon as somewhat relieved, it would be impossible to say 
just which cases deserved to be included in tables, so I will 
attempt no statistics, but merely state the impressions I 
have drawn from its use. 
Without going into the finer distinctions of pelvic path- 
ology, I would say that in cases of moderately acute pelvic 
1 Polacco, Centralbl. f. Gyn., 1891, No. 50. 
2 Polacco, Am. J. Obst., Ap., 1894. 
3 Albertolelli, Am. J. Obst., Ap., 1894. 8 
ICHTHYOL IN GYNECOLOGY. 
inflammation, with much pain, but where an operation did 
not seem indicated, or where one if advised was refused, 
the method pursued was as follows :—Every third day after 
carefully drying the vagina, its vault was freely painted 
with ichthyol-glycerine, 10 per cent., or with pure ichthyol, 
followed by a pad soaked in the solution, which in turn was 
guarded by a dry pad to protect the clothing. In addition 
to this, full hot douches were sometimes employed. Some 
cases where they were not used improved quite as rapidly 
as the others. In perhaps a dozen cases ichthyol pills were 
given. No discomfort from them was noticed, except one 
or two dyspeptics complained of the taste of the eructations. 
Yon Xussbaum took fifty pills a day with no bad effects. 
Baumann says that doses of from three to five drachms 
daily cause merely copious watery discharges. On the 
other hand I cannot say that any of the patients taking the 
pills seemed materially the better for them. In nearly all 
the appetite improved, but this may have been due to im- 
provement in the general condition. In six cases of deep 
seated pelvic pain the ointment was tried, and possibly the 
very slight but positive relief that was observed may have 
been due to massage. 
In a number of cases I used a suppository containing 
m iii. which was allowed to dissolve in the vagina every 
night, with very satisfactory results, and now I frequently 
order them. Care should be taken that in such supposi- 
tories the drug is thoroughly mixed with the vehicle, and 
not merely enclosed in a capsule as is a favorite practice in 
France. I regard it as distinctly undesirable that the pure 
drug should be used for any length of time without the 
physician’s control. 
Looking back on this class of cases, I can only say that 
they seemed to improve faster than where other methods 
were employed. The relief to sharp pain was fairly con- 
stant and immediate, and in a few cases a single application ICHTHYOL IN GYNECOLOGY'. 
9 
gave almost entire relief. To be sure, sometimes a single 
painting with some other drugs has a very prompt action, 
but I do not think quite so often. Dull aching pain was 
not so easily reached, but it was the exception that some 
relief was not experienced after a number of applications. 
I found rather better results to follow the use of the pure 
drug than did that of the glycerine solution, although care 
had to be taken not to desquamate the vagina—a result 
which sometimes follows also the over-enthusiastic use of 
tr. iod. 
Admitting its anodyne effect, the following case will 
show that it also sometimes has a resorbent action : 
hi. R., first seen Sept., 1892. Twenty-five. Married 8 years. 
Two children, the youngest five. Neither labor instrumental, but 
a somewhat long puerperium after the last. Since then three 
miscarriages, lias not been well since the last miscarriage in 
March, 1892. 
Three weeks later had an offensive discharge for a few weeks. 
Early in July had an attack of severe abdominal pain, and a pel- 
vic abscess was opened by the vagina, but soon allowed to close 
up. A month later had a return of the pain, amounting to agony 
when the bowels moved. Catamenia were fairly regular, but not 
marked by any great increase in the pain. When first seen she 
was in good general condition, except for a slight afternoon rise 
in temperature. The posterior vagina and both sides of the pelvis 
were filled by a very hard board-like mass, in which nothing defi- 
nite could be made out. In fact its hardness was such that a 
previous examiner had been led to make the diagnosis of malig- 
nant disease. There was exquisite local tenderness. The patient 
was put on applications of thiol, which is practically the same as 
ichthyol, alternating with the latter, witli hot douches, which she 
had been taking previously. After ten days’ treatment the mass 
was much softer and less tender, and the pain had vanished. 
Defecation even was now painless. After a month the uterus 
was easily felt anteriorly, and it was fairly movable, while to the 
left and posteriorly was felt a soft, enlarged and fluctuating tube, 
and behind the uterus a tender and indurated ovary closely con- 
nected with a hard mass filling the right pelvis. Improvement 
continued under treatment, and the patient was subjectively per- 
fectly well until September, 1893, when the old symptoms re- 
turned, and the pelvis was again found filled with exudate. This 
time the pain was controlled by a single application, and a week 10 
ICHTHYOL IN GYNECOLOGY. 
later the anatomical condition was much improved. In October 
catamenia lasted longer than usual, hut the patient said she had 
never felt better hi her life. By December there were only traces 
of exudate left, arid what fluid the tubes previously contained had 
now been evacuated. Douches were not used in this last attack, 
yet improvement was quite as rapid as in the first. 
This good result was by no means unique. Very possi- 
bly there would have been equally prompt relief under 
other treatment, but I have seldom seen cases like it do so 
well when other treatment has been employed. 
Cases of chronic endometritis seen at comparatively long 
intervals were treated with pure ichthyol applied to the 
fundus, after a preliminary partial disinfection with lysol 
or creolin, and the relief from local pain and dragging was 
constant, and generally there was in a short time much less 
leucorrhoea. Of course very many obstinate cases finally 
came to curetting, but my impression is that as many, if 
not more, were cured or relieved than were by any other 
treatment. In no case was there any real pain from the 
application, i.e. that was not merely due to the passage of 
the applicator, or to the preliminary slight dilatation. It 
is to be remembered that cramps following the intra-uterine 
use of iodine are by no means rare. Pee spoke of hemor- 
rhage sometimes following the intra-uterine use of ichthyol. 
I have not seen any such immediate effect, but in two cases 
the following catamenia were prolonged much beyond pre- 
vious experience, an effect which had not followed the pre- 
vious use of iodine, nor, on the other hand, had much 
improvement. Both these cases were subsecpiently prac- 
tically cured by ichthyol. I have in mind several other 
cases previously treated by other gentlemen by the ordinary 
means which were promptly cured by ichthyol. 
Iii packing adherent retroverted uteri it has been my 
custom to dip the first two pads in the ichthyol-glycerine 
solution. I am convinced that since I have done so I have ICHTHYOL IN GYNECOLOGY 
11 
seen many such uteri loosen up and become replaceable that 
otherwise would have been very obstinate. Another ad- 
vantage is that it being decidedly inimical to many forms 
of bacterial life, as shown by Fessler1 and Abel,2 when 
such a packing is removed it is much less offensive than the 
ordinary glycerine pack—except, of course, for its charac- 
teristic ichthyol odor. Here let me say that I have never 
had a gynecological patient complain of its odor. Purely 
as an antiseptic its value is not very great, but prolonged 
immersion in the pure drug destroys streptococci. 
In erosions naturally the chief attempt has been to re- 
move the cause, but in the cases where intra-uterine treat- 
ment was not adopted there was improvement, although 
perhaps no more marked than under other treatment. 
I have not tried it in enough cases of gonorrhoea to form 
any opinion as to its value. In four the few times it was 
applied was followed by little result, while in a fifth obsti- 
nate case the very free leucorrhoea almost stopped after six 
applications to the endometrium, combined with daily lysol 
douches. To which is due the credit I am not certain. 
Lately it has been used quite extensively in the male ure- 
thra. I tried it in one case of female urethritis with no 
effect that I coidd see. This case promptly improved with 
nitrate of silver. The results of Bloch, Jadassohn, Col- 
umbini and Jullien warrant further experimentation in this 
direction. 
I have used the salve and the pure drug in a number of 
cases of pruritus of the vulva and anus. There was im- 
provement, but no cure in all. One severe case was painted 
extensively with a solution in collodion (1-8), and after 
the somewhat natural stinging had vanished relief was com- 
plete for some time. 
1 Fessler, Klin, exper. Studien. uber chir. Krankheiten. 
2 Abel, Centralbl. fur Bakt. u. Parasit., 1893, XIV., No. 13. 12 
ICHTHYOL IN GYNECOLOGY. 
In a few cases of painful hemorrhoids it seemed to re- 
lieve the discomfort by lessening the congestion. 
The use of the collodion solution is most satisfactory in 
cracked nipples. 
Conclusions. 
1. While ichthyol is by no means the gynecological 
panacea that some observers have claimed it to be, still it 
has sufficient approved value to deserve a very high place 
in our list of remedies. 
2. That while its chief action is to relieve pain it does 
possess certain resorbent qualities, which in some cases are 
relatively powerful. 
3. That its use is unattended with danger or discomfort . 
4. That the use of the pure drug is generally more sat- 
isfactory and reliable than that of solutions. 
5. That it has not yet been proven that it has any gyne- 
cological value other than as a local application. 
Articles on the subject not referred to are: 
Gadde, Beitrag z. Aus. u. In. Anwendung des Ichthyols. Ther. Mon- 
atshft. Berl., 1890, IV., 121. 
Eschen, Iktyelets Anvendelse I. Gynsekologien. Gyn. Og Obst. Med., 
1891, VIII., 281-321. 
Schultz, Pest. Med. Chir. Prcsse, 1892, XXVIII., 787. 
Marjanchik, (Treatment of Endometritis by Ich.) Vrach, 1892, XIII., 
799-855. 
Ilinski, (Application of Ich. in Therapeutics, Surgery, Dermatology, and 
Gynecology), Moskow, 1892. 
Cocq, Note Sur Ich. in Metrites. Clin. Brux,, 1893, VIII., 180, 212,